A list of the most recent deficiencies for Trailpoint Village. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-08-29 | 2023-10-15 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-01-18 | 2023-03-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-18 | 2023-03-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-18 | 2023-03-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-18 | 2023-03-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-18 | 2023-03-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-18 | 2023-03-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-01-18 | 2023-03-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-18 | 2023-03-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-01-18 | 2023-03-21 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-01-18 | 2023-03-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-18 | 2023-03-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-01-18 | 2023-03-21 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2023-01-18 | 2023-03-21 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-01-31 | 2023-02-20 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-01-04 | 2023-02-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-01-04 | 2023-02-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-01-04 | 2023-02-15 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-01-04 | 2023-02-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-01-04 | 2023-02-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-04 | 2023-02-15 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-01-04 | 2023-02-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-04 | 2023-02-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-01-04 | 2023-02-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-04 | 2023-02-15 | N |
| Respond appropriately to all alleged violations. | Health | 2021-08-30 | 2021-09-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-19 | 2021-06-25 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-10-21 | 2019-11-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-10-21 | 2019-11-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-21 | 2019-11-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-21 | 2019-11-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-21 | 2019-11-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-10-21 | 2019-11-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-10-21 | 2019-11-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-21 | 2019-11-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-21 | 2019-11-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-08-23 | 2019-09-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-23 | 2019-09-22 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-08-23 | 2019-09-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-23 | 2019-09-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-07-19 | 2018-09-14 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-07-19 | 2018-08-18 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-07-19 | 2018-08-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-07-19 | 2018-08-18 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-07-19 | 2018-08-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-07-19 | 2018-08-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-19 | 2018-08-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-07-19 | 2018-08-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-07-19 | 2018-08-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-07-19 | 2018-08-18 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-07-19 | 2018-08-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-07-19 | 2018-08-18 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2018-07-19 | 2018-08-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-07-19 | 2018-08-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-07-19 | 2018-08-18 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2018-07-19 | 2018-08-18 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-07-16 | 2018-08-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-07-16 | 2018-08-15 | N |
| Respond appropriately to all alleged violations. | Health | 2018-07-16 | 2018-08-15 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-07-16 | 2018-08-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-16 | 2018-08-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-07-16 | 2018-08-15 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-07-16 | 2018-08-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-16 | 2018-08-15 | N |
